Provider Demographics
NPI:1043216567
Name:WALLS, ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:WALLS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 SW UMATILLA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:541-504-3900
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:628 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1506
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:541-504-3907
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5630122300000X
ORD7828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1305630Medicaid